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Page 8 of 9 Shiozaki et al. Mini-invasive Surg 2020;4:50 I http://dx.doi.org/10.20517/2574-1225.2020.31

operative bleeding and improved the quality of lymphadenectomy. We also found that total operative
bleeding was significantly less in patients treated with the laparoscopic transhiatal approach (216.2 ± 193.1 mL)
than in those treated with right thoracotomy (549.5 ± 390.4 mL), and that the total number of resected
lymph nodes did not significantly differ between the two groups (laparoscopic transhiatal approach: 35.9 ±
[11]
16.0/right thoracotomy: 40.1 ± 20.3) .

On the other hand, a detailed understanding of mediastinoscopic esophagectomy is essential for the success
of this procedure. The narrow mediastinal surgical space needs to be secured by appropriate retraction
and pneumomediastinal pressure in this method. In addition, we sequentially expose the mediastinal
organs using a long surgical device, and, thus, this surgery is similar to “tunnel construction”. A detailed
understanding of the 3D anatomy of the mediastinum is important. We routinely construct 3D images
from CT scans and attempt to recognize the specific anatomy of major vessels preoperatively. A detailed
understanding of pitfalls is indispensable to ensure safety, and the development of procedures to overcome
the pitfalls of this approach, such as the tangential view, is needed.

Robot-assisted transmediastinal radical esophagectomy was recently reported to achieve a better quality
of life than open esophagectomy in both retrospective and prospective studies [19-22] . Larger studies and
prospective analyses are needed for comparisons between robotic and laparoscopic transhiatal approaches.
In the future, the development of novel instruments, such as small-caliber devices with multiple joints,
and lightweight robotic single-port techniques may be key innovations in transmediastinal radical
esophagectomy.

CONCLUSION
Laparoscopic transhiatal esophagectomy provided a good surgical view and safe en bloc mediastinal lymph
node dissection in patients with esophageal cancer. The standardization of surgical procedures and a
detailed understanding of the mediastinal 3D anatomy and specific pitfalls are important for the success of
this approach.

DECLARATIONS
Authors’ contributions
Wrote the manuscript: Shiozaki A, Fujiwara H, Otsuji E
Performed surgeries: Shiozaki A, Fujiwara H, Konishi H
Designed the research: Shiozaki A, Fujiwara H, Konishi H, Shimizu H, Kudou M, Arita T, Kosuga T,
Morimura R, Kuriu Y, Ikoma H, Kubota T, Okamoto K, Otsuji E

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Our work conforms to the guidelines set forth in the Helsinki Declaration concerning human and animal
rights, and we followed the policy concerning informed consent. The study of this surgical procedure was
reviewed and approved by the Kyoto Prefectural University of Medicine Institutional Review Board.